What the panel ordered
Petition for Reconsideration granted; Findings of Fact and Order of June 21, 2024 affirmed except amended to find the microdiscectomy surgical procedure reasonable and necessary; request for surgery granted.
Applicant sought reconsideration of the Findings of Fact and Order issued on June 21, 2024, which denied the request for microdiscectomy surgery; the WCJ issued a Report and Recommendation to deny the petition; the Appeals Board granted reconsideration and issued a Decision After Reconsideration.
What was disputed, and how it came out
Each issue the panel decided, with the reasoning it gave. An outcome is what this panel did on this record — not a rule, and not a prediction.
The Appeals Board found that the applicant met the MTUS criteria for the microdiscectomy surgery based on substantial medical evidence from Dr. Nussbaum, despite initial denials and contrary opinions from other physicians, and ordered the surgery to be granted.
From the decision · page 7II. Applicant contends that the WCJ erroneously failed to find that the microdiscectomy surgical procedure in the May 10, 2023 RFA is reasonable and necessary. Specifically, applicant contends that Dr. Nussbaum's reporting of applicant's symptomatology against the applicable criteria demonstrates that microdiscectomy surgery is reasonably required to cure or relieve her from the effects of injury. We observe that Labor Code section 46001 provides that an employer must provide "[m]edical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." (§ 4600 (a).)
The facts that decided it
What the panel treated as outcome-determinative, and which side it favoured.
Dr. Nussbaum's medical reports established clinical evidence of radiculopathy and muscle weakness consistent with MRI findings supporting microdiscectomy surgery
Favours Applicant prevailed
This medical evidence met the MTUS criteria and was relied upon by the Appeals Board to find the surgery reasonable and necessary
From the decision · page 8In this case, the record shows that applicant's physician, Dr. Nussbaum, initially recommended that she receive lumbar epidural steroid injection and the request was non-certified. (Ex. 102, PTP Report of May 3, 2023, p. 1.) Applicant underwent an MRI of the lumbar spine, which revealed Grade I spondylolisthesis at L5-S1 and "diffuse disc bulging which was left paracentral contacting the exiting S1 nerve root. (Id., pp. 1-2.) These findings, the physician reasoned, provided "[c]linical evidence for S1 radiculopathy" and warranted microdiscectomy at
Applicant's credible testimony of persistent pain and functional limitations despite conservative treatment
Favours Applicant prevailed
Supported the finding that surgery was necessary to relieve injury effects
From the decision · page 6consider surgical intervention." (Id. at p.5). Dr. Burnham then states that if conservative measures such as PT, Chiro and injections fail then he recommends "Total Disc Replacement versus Anterior Interbody Fusion." (Id.). The doctor finishes up by stating as follows: "Finally, while not opposed to the consideration of surgical intervention, in my opinion there is indication for at this time are limited and due to her complaints of pain more so than objective findings on XR or physical exam." (Id.)... Applicant testified at the Trial of 06/03/2024 that she had pain in her back that goes down both legs along with numbness in both legs (MOH/SOE 06/03/2024 p.5). She had more pain in the left leg and described a pins-and-needles sensation along with weakness in her right leg (Id.).
What the panel did with the medical opinions
The role the physician served, and the weight the opinion carried. Physicians are named here as the decision names them; we do not score them.
Recommended microdiscectomy surgery at L5-S1 based on MRI findings and clinical symptoms consistent with radiculopathy; found surgery reasonable and necessary under MTUS guidelines.
Dr. Nussbaum's reports provided clinical evidence of radiculopathy and muscle weakness consistent with MRI findings, supporting the need for surgery.
From the decision · page 8In this case, the record shows that applicant's physician, Dr. Nussbaum, initially recommended that she receive lumbar epidural steroid injection and the request was non-certified. (Ex. 102, PTP Report of May 3, 2023, p. 1.) Applicant underwent an MRI of the lumbar spine, which revealed Grade I spondylolisthesis at L5-S1 and "diffuse disc bulging which was left paracentral contacting the exiting S1 nerve root. (Id., pp. 1-2.) These findings, the physician reasoned, provided "[c]linical evidence for S1 radiculopathy" and warranted microdiscectomy at
Recommended conservative treatment and possible total disc replacement or anterior interbody fusion if conservative measures fail; did not oppose surgery but found indication limited based on objective findings.
Dr. Burnham's opinion did not contradict the need for microdiscectomy but suggested alternative surgical options and recommended further record development.
From the decision · page 5A second-opinion surgery evaluation was conducted by Dr. Walter Burnham on 04/25/2024 (Exhibit 108). Dr. Burnham notes Applicant complains of low back pain that radiates into the bilateral lower extremities and notes that Applicant "is not restricted in her daily activities." (Id. at p.2). Dr. Burnham reviews the 12/21/2023 MRI report noting spondylosis most prominently at L4-L5 with stenosis and crowding of nerve roots at that level (Id. at p.4). Under the "Treatment Plan" heading, Dr. Burnham notes that Applicant "does not want to generally
The rules the panel named
Authorities as the decision cited them, with how this panel applied each one.
California Labor Code
Labor Code section 4600(a) requiring provision of medical treatment reasonably required to cure or relieve injury effects
Applied to determine entitlement to microdiscectomy surgery
From the decision · page 7II. Applicant contends that the WCJ erroneously failed to find that the microdiscectomy surgical procedure in the May 10, 2023 RFA is reasonable and necessary. Specifically, applicant contends that Dr. Nussbaum's reporting of applicant's symptomatology against the applicable criteria demonstrates that microdiscectomy surgery is reasonably required to cure or relieve her from the effects of injury. We observe that Labor Code section 46001 provides that an employer must provide "[m]edical, surgical, chiropractic, acupuncture, and hospital treatment, including nursing, medicines, medical and surgical supplies, crutches, and apparatuses, including orthotic and prosthetic devices and services, that is reasonably required to cure or relieve the injured worker from the effects of his or her injury." (§ 4600 (a).)
California Labor Code
Labor Code section 4604.5 regarding evidentiary burden and MTUS guidelines
Applied to assess medical necessity under MTUS guidelines and burden of proof
From the decision · page 8The Legislature amended section 3202.5 to underscore that all parties, including injured workers, must meet the evidentiary burden of proof on all issues by a preponderance of the evidence. Accordingly, notwithstanding whatever an employer does (or does not do), an injured employee must still prove that the sought treatment is medically reasonable and necessary. That means demonstrating that the treatment request is consistent with the uniform guidelines (§ 4600, subd. (b)) or, alternatively, rebutting the application of the guidelines with a preponderance of scientific medical evidence (§ 4604.5). (Sandhagen, supra, at p. 990.)
What proof carried it
The evidence the panel weighed, by kind.
Applicant's testimony of persistent back pain, numbness, and functional limitations despite conservative treatment
From the decision · page 6consider surgical intervention." (Id. at p.5). Dr. Burnham then states that if conservative measures such as PT, Chiro and injections fail then he recommends "Total Disc Replacement versus Anterior Interbody Fusion." (Id.). The doctor finishes up by stating as follows: "Finally, while not opposed to the consideration of surgical intervention, in my opinion there is indication for at this time are limited and due to her complaints of pain more so than objective findings on XR or physical exam." (Id.)... Applicant testified at the Trial of 06/03/2024 that she had pain in her back that goes down both legs along with numbness in both legs (MOH/SOE 06/03/2024 p.5). She had more pain in the left leg and described a pins-and-needles sensation along with weakness in her right leg (Id.).
MRI findings showing disc bulging contacting the S1 nerve root consistent with clinical symptoms
From the decision · page 9Significantly, the record also shows that Dr. Nussbaum reviewed the MRI and found that its findings of "diffuse disc bulging which was left paracentral contacting the exiting S1 nerve root" were consistent with applicant's clinical symptoms giving rise to predicted pain on the left side. Although the MRI's findings do not state that applicant's disc bulging contacting the exiting S1 nerve root compresses the nerve root, it objectively describes the source or mechanism of applicant's symptomatology in line with the MTUS. (Ex. 101, Correspondence from Sedgwick, May 18, 2023, pp. 8-9; Ex. 102, PTP Report of May 3, 2023, pp. 1-2; Ex. 2, PTP Report of June 14, 2023, pp. 1-2.) Thus, the treatment is appropriate under the MTUS guidelines, guidelines which allow the physician to exercise clinical discretion in their application. (Ex. 101, Correspondence from Sedgwick, May 18, 2023, pp. 8-9.)
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